Wednesday, September 26, 2007

HIV-Positive Kidney Transplants

I went to an interesting talk yesterday regarding performing kidney transplants in patients with HIV infection.

As most people know, HIV disease is associated with a high rate of infections. In addition, it's also associated with kidney disease, especially in African-American patients. So the question comes up: can you give a patient with HIV disease a kidney transplant?

Traditionally the answer has been no. The major reason for this is that the medications required for a normal kidney transplant are immunosuppressants, which are taken to minimize the chance of a kidney rejection. It's thought that if HIV patients (who are already immunosuppressed) were given these meds, this "double hit" on the immune system would render them extremely prone to infection.

Things have changed in recent years, however. For one thing, the immunosuppresant medications are better and rejection is becoming less common. More importantly for HIV patients, the introduction of new HIV meds in the early 90s has led to a dramatic increase in survival and immune system recovery. So there are some transplant centers--ours at Harvard is not yet one of them--who have done kidney transplants in highly selected and motivated HIV patients. The results as they were presented at this recent meeting were pretty encouraging, and it seemed that HIV+ patients with kidney transplants did about as well as HIV- patients with kidney transplants.

However, these patients have to take a mind-boggling number of pills. They typically have to take 2-3 pills to keep their HIV in check, typically three different immunosuppressants for their transplant, at least two medications to prophylax against pneumocystis pneumonia and CMV disease (common diseases in the transplant patient), and likely will have to take medications to control their diabetes, high blood pressure, and high cholesterol levels that that both the HIV meds and the immunosuppressant meds have as side effects. In a sense, it's kind of like trading in one disease for another, though I think most patients would say that the trade is worth it.

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